HomeMy WebLinkAboutDONALD C SCHROEDER #2 TR 6-B
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street- Anchorage, Alaska 99501 Telephone 264-4720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
F:
MAI LI N~IDR ESS. --
~ Z Manufacturer M
Li~ ~ci~lJons, IF HOMEMADE: Inside length~ Width ~ Liquid depth
~ -- ~ Manufacturer ' y~ Material Liquid capacity in gallons
~ No. of lines Length ~ch~e T~I.~ o~s Trench w~ inchesDistanCeef~betwe~na~or~arealines~
~ O ~ : Top of tile to finish grade~ /~/ - Material beneath tile / ~ inches Total
~ Length 'Width ~e~th PERMIT NO.
~< ~ Type of crib Crib diameter ~ ~/ ~b depth Total effective absorption area
~ Well Building foundation Nearest lot line
~ DISTANCE TO:
." Class ~.~j ~/~/~ Driller Distance to lot ,,.e PERMIT .O.
~ ~ ' ~ldin~ ~ou~dation ' Sewer line Septic tank Absorption area(s)
~ DISTANCE TO:
OTHER
PIPE MATERIALS
SOIL TEST RATING ~
INSTALLER
REMARKS
APPR~D// ~?~"' ...... ?:~','~f~' DATE LEGAL ~ & ~ ~GINE~RIN~ '
72-o ~v. 3/78)
[] SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION
825 L. Street, Anchorage, Alaska 99501 264-4720
SOILS LOG - PERCOLATION TEST
[]~'/PERCO LATION
TEST
PERFORMED FOR:
LEGAL DESCRIPTION:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
~ Ru,se;I L, Oy~fer
N~;~, 4286-E
SLOPE ' ~ITE/pLAN' /
WAS GROUND WATER
ENCOUNTERED?
IF YES, AT WHAT
DEPTH?
Grcss Net Depth to Net
Reading Date Time Time Water Drop
PERCOLATION RATE /~ (minutes/inch)
r-1 LI [-~ ][ F: I '
DEPRRTMEN.T L
:=:25 '" L '"
;-I E L L R ['~ [:'
F' E R I"11 T N 0. ':: :::-". 08 ]: ? )
HEFILTH RND EN'v'IRONMENTRL . .<OTECTtC,[;~//: i
STREET., RNCHOF.:RGE., RK. ':J.'~.5E~L ~ (q'.~-~ ..~ ~--~
264-4?20 ~ ~'- ~--h~I .~
,-Jl"-.I--"--; T TE ~';EL,-IEE." PERI'"1 T T / ,~.
...' ,' ~,-:.t4.~,:t
LOT =.I.-' E
999999 SQI.IRRE FEET
, ' .... I ..... , "-I','''= =,UIL'~'- RRTII'.,IIj ,'..'SI]:.! FT,.. BR',= · '-5
I'IFI,...,IMLIM NJrlE, EF, F~F BE[:RuLII:, = 4 ...... t,_,,_
- ,,~- , , Fi
THE F.:EI.T.!LIIF.:E[:, ClZE OF THE SOIL PIE,::,I_IRFTI_N SYSTEM IS'
[:.EPTH= ~ LEt-.~',3TH= ,3F-:R'..-"EL E:'EF'TH=
THE LENGTH DIMENSION IS THE LENGTH <IN FEET) OF THE TRENCH OR DRFIINFIELD.
THE DEPTH OF R TRENCH OR PIT IS THE DISTRNCE BETWEEN THE SURFRCE OF THE
GROUND.RND THE' BOTTOM OF THE EXCRVFITION (IN FEET).
THE T'IF:Ef-4E:H I~ I E:,T#a l"=~. FEET.
THE GRRVEL DEPTH IS THE MINIMUM DEPTH OF' GRFIVEL BETWEEN THE OUTFRLL PIPE
FINE) THE BOTTOH OF THE EXCRVFITION (tN FEET).
PERMIT RPPLICRNT HRS THE RESPONSIBILITY TEl INFORM THI'-] DEPRRTMENT DURING THE
INSTFILLFITION INSPECTIONS OF RNY WELLS FIDJFICENT TO THIS PROPERTY FIND THE
~4UI'"IE:ER OF F,E:,IE. EN_.E:, THRT THE WELL NILL :,EE,,E. //
BRCKFILLING OF RNY S'T'STEM WITHOUT FINRL INSPECTION RN[:, RPPROVRL BY THIS
DEPRR. TMENT WILE BE SUBSECT TO PROSECUTION
MINIMUM DISTRNCE BETWEEN R WELL RND RNY ON-SITE SENRGE DISPOSRL SYSTEM IS
· 00 FEET FOR R PRIVRTE WELL OR ~50 TO 200 FEET FROM R PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC NELL
MINIMUM DISTRNCE FROM R PRIVRTE WELL TO R PRIVFITE SEWER LINE IS 25 FEET RND
TO R COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS RRE REQUIRED RND MUST BE 'RETURNED TO THE DEPRRTMENT WITHIN ~0 DFIYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS WRY RPPLY, SPECIFICRTIONS RND CONSTRUCTION DIRGRRMS RRE
RVRILRBLE TO INSURE PROPER INSTRLLRTION.
F" E IF: F.1 I 'T E ::-:: F' I IF." E $ E:.. E C: E F-I E: E IF' _~:: 1 .. ::L 9 :-22: '-~::
i CERTIFY THRT
±: I RM FRMILtRR WITH THE REQUIREMENTS FOR ON-SITE SEWERS RND WELLS FIS SET
FORTH BY THE MUNICIPRLITY OF RNCHORRGE.
2: I WILL INSTFILL THE SYSTEM IN RCCORDRNCE WITH THE CODES.
.~: I UNDERSTRND, THRT THE ON-SITE SEWER SYSTEM MRY REQUIRE ENLRRGEMENT IF THE
RESI[:,ENCE '- '- '
I:, REMI]E:,ELE[:, TO INC:LLIE:,E I1UF..E THRN 4 BEDROOMS.
'= I GNE[:, '
RF'PL I CRNT EDNRRD TIJRNER
__.[:,RTE_
I SSLIE[:, BY_,T=.._..
· '.-~ ~'"" 'c F ..<~~ - . ~ "i' !
WATER WELL RECORD
STATE OF ALASKA (.~,,
DEPARTMENT OF NATURAL RESOURES
Division of Geological ~ Geophysical Surveys
LOCATION OF WELL (Pleoee complete either la, lb or
~l.orouoh S~bd,v,.,o. I Lot
I~. DISTANCE AND DIRECTION FROM ROAD INTERSECTIONS
Street Addreee and Area of Well Location
WELL LOG
Material Type
Feet Below
Surface
Drilling Permit No,
A.D.L, No.
Top Bottom
," ,? '",
16, WATER WELL CONTRACTOR'S CERTIFICATION:
OWNER OF WELL: *'~. : ;.
Address:
4. WELL DEPTH: (final)
- ,~ .-? ft.
5. DATE OF COMPLETION
:~- ,,;~ _ ,~ .
6. E~ Cable tool ~ Rotary L-'~l Dri ye n L_-~ Dug
[] Auger ~Jetted []Bored [~ Other:
7. USE: :~'-~ Domee¢lc [] Irrigation
[] Test Welt
Public Supply [] Industry
Re~hor~e [] Comma.col
Oilier:
8. CASING: ~_~ Threaded &[~.~ Welded
diom,.__~.~_._in, to ...... :_ ft. Depth Weight ......... lbs./fl,
diam._ ...... in. to ....... fi, Depth ,~tickup , /:~ ft.
9. FINISH OF WELL:
Type: ........................ Diameter:
Stat/Me ~h Size: ............... Length:
Set between ft end ft.
Back filling ................ Grov~l pack
Equipment asod:
ti, PUMPING~LEVEL below land surface and YIELD
____ft, after ........... hrs. pumping .......... g,p.~.
ft. offer .......... hrs, pumping ........... g.p m.
,~.~.o~,N~ we,, ~..~.,~:
15. PUMP: (if o,vailoble) HP
Length of Drop Pipe ft,
14. REMA~KS:
This welt was drilled under my jurisdiction and tl~is report is truc to the best of my knowb~dg{ and belief;
Registered Business Name' Conlroct License Number
Signed: : ~ '
, ~ Authorized Represenletive
Form 02'WWR (11/81)
Copy Distribution; WHITE-State DGGS~ PIN~-D~iller~ CANARr'-Customer
MUNICIPALITY OF ANCHORAGE
DIVISION OF ENVIRONMENTAL HEALTH
DEPARD4ENT OF HEALTH AND ENVIRONMENT.~L PROTECTION
APPLICATION FOR HEALTH AUTHORITY APPROVAL CETU?IFICATE
1. General Information
Application Date
(a) Legal Descniption (include %et, block, subdivision, section, townsh__ip/ range)
C T . c leO £D
Location (addness or 5~r~ctions)
(c) A991icant is (check one) Lending Institution ~ ; (A~er/builde~;
Buye= ~ ; Other ~ (explain);
(e) t~eal Estate Co. & Agent__
Address
Telephone
2. Type of F~sidence
Sing!e-Family .~
Number of Bedrooms
3. 'Water Supply
Individual Well
Multi-Family
Other (describe)
Ccam~nity ~ Public
Note: If cu~,~unity well system, must have written ccnftrmation frcm the State
Department of Environmental Conservation attesting to the legality and status.
Is the well adequate f(Ie the number of bedrocn~ specif%ed in this HAA (Y/N)
4, Sewage Disposal
~r:site ~ Public ~ Comaunity ~ Holding Tank ~
Is the wastewater disposal system adequate for the numbe~ of bedrooms
[Page 1 of 2]
2-15-84
5. Engineering Firm Providin~ Inspections, Tests, Data and Information
I certify tha..~-~ha~ checked, }~e~ified,
effec~~ da~ ' ' '
Nan~ ~f
c~ conformed to all MOA HAA Guidelines in
Date ~_~
Telephone
Date
(ENGINEER SEAL)
6. DHEP Approval
Approve d for
Ap~o~d ~
. Disap~oved ~ Conditional
Terms of Conditional Approval
The Municipality of Anchorage Department of Health and Environmsntal P~otection does
not guarantee the continued satisfactory ~erformance of the water, supply and/o~ the
wastewate~ disposal system. This approval indicates that, as of the validation date
shcy~n above, based on the data and infoz~nation furnished by an engineer registered in
the State of Alaska, the water supply and wastewater disposal system, is safe and func-
tional for the number of bedrc(mls and type of structure indicated.
(DHEP SEAL)
7. to/~ followingS_dress:
KB2/dS/s
[Page 2 of 2]
2-15-84
ae
MgNICI?ALITY OF ~NCHORAG~ (MOA)
HEALTH AUTHORITY APPROVAL (HAA)
CHECKLIST - FEBRUARY 1984
MUNICIPALITY OF ANCHORAGE
DEPT. OF HEAl.TH &
ENVIRONMENTA~ PROTECTION
APR ~ ~o
RECEi.~VED
Well Log P~esent ~gl~ ~/ ' Date Camgleted X/~C/ ~ ~
Static Wate~ ~1 / ~ ~t At ~ ~
Elea~eal Wi~ng in ~n~i~ ~essi~ ~nd ~l~ead-~
~p~ation Distan~s ~ ~
To ~ptic~olding Ta~ ~ ~t /~ ; ~' ~joini~g Lots
,,~e, s~e ~,~ ~u~, . ~ ~/~~~~ ............
sz~c~0~z~ ,T~ ~A
.te Instal~_. ~/~~ ~/ - Si. /~~ NO. ~ C~~nts
~1~ ~' , ..... ~. ._ ''. ....
~o~ng ~a~ ~g.-we~ ~a~ (~) ~/J , ~a~ ~~ tank
~ation Distan~s ~ ~g~i~olding Ta~:
TO ~o~ty ni~ ~ ~ ~ TO Dis~al Field ,, . ~
TO ~te~ ~i~i~ Li~ ~ ~ To S~, ~nd, ~e, ~ ~jo~ ~aina~
co~ ~/~ .....
Co~nts
[Page 1 of 2] 2-1,5-84
Ce
ABSORPTION FIELD DATA
Date Installed , ~7/,Zl~-~, , , Length of Field /20 /~,
Width of Field/~/~ /~ Depth of Field ~
Gravel Bed Thickness /~' /? ........
Squa=e Feet of Absorption/~ea ~ Standpipes P=ese~t~
Depression over Field (~N~/ Date of Last Adequacy Test
Results of Last Adequacy Test
Separat~ion Distance f~cm AbscNption Field%
To te=-Supply To P operty nine
TO Building Foundation '~
~ To Existing or Abando)aed System cn
To Cutbank(if .~resent)
To Stream/Pond/Lake/c~ Majo= Drainage Cou=se ,
To Driveway, Pa=king A=ea, c~ Vehicle Stc=age A=ea /~'- / -~
C~;~-~-~ nt s
D. LIFT STATION
Date Installed Dizens ions
Sizs in Gallons ~//~/~ Manhole/Access (Y/N)
"Pump On" Level at , ..~..~ ~ "Pump Off" Level at
Tested for Pumping Cycles du~ing Adequacy Test,.
Wsets MOA
Electrical Codes (Y/N)
Cc~ents
[Page 2 of 2]
**
~ed~oom Rating A~ainst HAA Request
~ verified, c~ confCZ~d to all MOA HAA Guidelines in effect
' '~'~'~'--2-15-84
HEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
TELEPHONE (907) 562-2343 ANCHORAGE INDUSTRIAL CENT£R
· 5633 B Street
Drinking water Analysis Report for Total Coliform Bacteria
TO BE COMPLETED BYiWATER SUPPLIER
Water S~tem~~ ( ~~ ~ ~ /_Phone No.
Mailing ~dre~
CiW State Zip
t. Mo. D~y ', Ye~
O Routine
D Check ~mple (for routine sample ~ Treated Water
~eclal/ with labpu~oseref, no. ') ~treated Water
SAMPLE
NO.
3 I J
TO BE COMPLETED BY LABORATORY
?
Analys'is shows this Water SAMPLE to be:
,~atis!actory
[] Unsatisfactory
[] Sample too long in transit; sample should
not b~ over 30 hours old at examination t~
indicate reliable results. Please send new
sample via special delivery mail.
!
Date Received
Time Received
/AnalY~cal Method:
Fermentation Tube
A~"Membrane Filter
Lab Ref. No. Result* Analyst
I FTq_
I
1
eNO of colonies/lO0 mi Or NO Of PosJl~ve Dort~or~l.
READ INSTRUCTIONS
BEFORE
COLLECTING SAMPLE
06-1220(b)
Rev. 1983
BACTERIOLOGICAL WATER ANALYSIS RECORD
i
Membrane Filter:. Direct Count
Verification: LTB
Final Membrane Filter Results
~eported By_ ,~_~ .~,~
TNTC-- Too Numerous To Count
Collformll00ml
BGB
T ~/ollformll00ml
Date,~. --~'~ --
Time: //,-/" ~,-.,,~ a.m.
p.m.
~ 8F-7211 1 30.00
List. on 89-5 1 42.90
Ni_~hs,,Dn~ 89-5 1.. , 5~.3~
ON PAY MENT ~ PA~ M~ NT STOPPED 6 DATE 9 CHECK 8OOK BALANCE